Unsgård Geirmund, Rao Vidar, Solheim Ole, Lindseth Frank
Neurosurgical Department, St. Olav University Hospital, Trondheim, Norway.
Norwegian University of Science and Technology, Trondheim, Norway.
Acta Neurochir (Wien). 2016 May;158(5):875-83. doi: 10.1007/s00701-016-2750-3. Epub 2016 Mar 19.
We have previously described a method that has the potential to improve surgery of arteriovenous malformations (AVMs). In the present paper, we present our clinical results.
Of 78 patients referred for AVMs to our University Hospital from our geographical catchment region from 2005 through 2013, 31 patients were operated on with microsurgical technique. 3D MR angiography (MRA) with neuronavigation was used for planning. Navigated 3D ultrasound angiography (USA) was used to identify and clip feeders in the initial phase of the operation. None of our patients was embolized preoperatively as part of the surgical procedure. The niduses were extirpated based on the 3D USA. After extirpation, controls were done with 3D USA to verify that the AVMs were completely removed. The Spetzler three-tier classification of the patients was: A: 21, B: 6, C: 4.
Sixty-eight feeders were identified on preoperative MRA and DSA and 67 feeders were identified and clipped by guidance of intraoperative 3D USA. Six feeders identified preoperatively were missed by 3D USA, while five preoperatively unknown feeders were found and clipped. The overall average bleeding was 440 ml. There was a significant reduction in average bleeding in the last 15 operations compared to the first 16 (340 vs. 559 ml, p = 0.019). We had no serious morbidity (GOS 3 or less). New deficits due to surgery were two patients with quadrantanopia (one class B and one class C), the latter (C) also acquired epilepsy. One patient (class A) acquired a hardly noticeable paresis in two fingers. One hundred percent angiographic cure was achieved in all patients, as evaluated by postoperative DSA.
Navigated intraoperative 3D USA is a useful tool to identify and clip AVM feeders. Microsurgical extirpation assisted by navigated 3D USA is an effective and safe method for removing AVMs.
我们之前描述了一种有可能改善动静脉畸形（AVM）手术的方法。在本文中，我们展示了我们的临床结果。
2005年至2013年期间，从我们的地理服务区域转诊至我校医院的78例AVM患者中，31例采用显微外科技术进行了手术。使用带神经导航的3D磁共振血管造影（MRA）进行手术规划。在手术初始阶段，使用神经导航3D超声血管造影（USA）来识别和夹闭供血动脉。我们所有患者均未在术前进行栓塞作为手术程序的一部分。根据3D USA切除病灶。切除后，用3D USA进行检查以验证AVM是否已完全切除。患者的斯佩茨勒三级分类为：A：21例，B：6例，C：4例。
术前MRA和DSA共识别出68条供血动脉，术中3D USA引导下识别并夹闭了67条供血动脉。3D USA遗漏了术前识别出的6条供血动脉，同时发现并夹闭了5条术前未知的供血动脉。总的平均出血量为440毫升。与前16例手术相比，最后15例手术的平均出血量显著减少（340 vs. 559毫升，p = 0.019）。我们没有严重的并发症（格拉斯哥预后评分3分及以下）。手术导致的新缺陷为2例象限盲患者（1例B级和1例C级），后者（C级）还患上了癫痫。1例患者（A级）出现了两个手指几乎难以察觉的轻瘫。术后DSA评估显示，所有患者均实现了100%的血管造影治愈。
神经导航术中3D USA是识别和夹闭AVM供血动脉的有用工具。在神经导航3D USA辅助下的显微外科切除是一种有效且安全的AVM切除方法。
